INCONTINENCE

DEFINITION

■ Continence: normal ability of a person to temporarily

store urine, with conscious control over the time and place
of voiding.
■ Incontinence: involuntary loss of urine that is
objectively demonstrable and is a social or hygienic
problem.
 TYPES OF URINARY INCONTINENCE

1. Extra urethral incontinence

2. Urge incontinence
3. Stress incontinence
4. Overflow incontinence
5. Reflex incontinence
6. Nocturnal enuresis
7. Giggle incontinence
8. Orgasmic incontinence
■ EXTRA URETHRAL INCONTINENCE

Loss of urine through channels other than the urethra is

called extra urethral incontinence.
Reason: Congenital abnormality ( eg: an aberrant ureter
draining into the vault of the vagina )
Fistulas ( commonly the result of trauma at pelvic surgery
such as hysterectomy in cases of endometriosis, infection or
carcinoma where the pelvic anatomy has been distorted.
Management: Reconstructive surgery.
■ URGE INCONTINENCE

Involuntary loss of urine associated with a strong desire to void.

Two main causes: 1) sensory urgency
2) motor urgency
■ Sensory urgency: due to hypersensitivity of the receptors in
the bladder wall and sometimes the urethra, caused by some
pathology such as infection, carcinoma or stones.
Thus, bladder fills- early and unwanted detrusor contraction either
spontaneously or in response to activity.
Cystitis – most common cause
Management: removal of the cause and teaching PFC and bladder
training.
■ Motor urgency: Involuntary detrusor contractions occur
during the filling phase. May be spontaneous or provoked
by activity such as walking or coughing.
May indicate a neurological disorder.
Second most common cause of urinary incontinence in
women in middle years and most common cause in the
elderly.
Management: Strong repeated PFM contraction to suppress
the overactive detrusor and bladder training.
Also, anticholinergic drugs in cases of neuropathy.
■ STRESS INCONTINENCE

The patient complains of Incontinence on stress, i.e. When the intra-

abdominal pressure is raised by coughing, sneezing or exercising.
Could be due to genuine stress Incontinence or due to detrusor
contractions provoked by these activities.
Genuine stress incontinence : condition in which there is involuntary
loss of urine when in the absence of a detrusor contraction the
intravesical pressure exceeds the maximum urethral pressure.
Detrusor activity is normal but the urethral closure mechanism is
incompetent.
Often associated with urgency- which is probably a heightened
awareness of any desire to void for the fear of leakage.
Reason: weakness and sagging of PFM
Weakness maybe due to
1. Trauma to muscle or adjacent
tissue from surgery or childbirth.

2. Damage to nerve supply to

sphincter or levator Ani from
surgery, childbirth or stretching.

3. Weakness from underuse.

4. Fatigue or stretching from over use

eg: repeated coughing, straining at
stool due to constipation, heavy
lifting and obesity
■ OVERFLOW INCONTINENCE

Involuntary loss of urine associated with difficulty in

escaping.
Urine is stored in the bladder and has difficulty in escaping.
Reason: impaired nerve supply to detrusor in cases of
diabetic neuropathy, spinal shock, cauda equina lesions.
Result is chronic urinary retention.
Eventually pressure in bladder rises- overcomes urethra
closure pressure- urine passes in small amount as a dribble
or spurt until pressure in bladder and urethral pressure
equates- significant amount of residual urine remains and
the pressure builds up again quickly.
Management: removal of cause.
■ REFLEX INCONTINENCE

Loss of urine due to overactivity of detrusor ( detrusor

hyperreflexia ) or involuntary urethral relaxation in the
absence of any perceived sensory desire to void and due to
neurological impairment.
It is seen in paraplegics, and the bladder empties
incompletely and without proper conscious control.
■ NOCTURNAL ENURESIS

Incontinence during sleep or ‘bed wetting’.

Vast majority of children who suffer from nocturnal ENURESIS
are dry by puberty.
Management: change of diet to reduce caffeine intake
Alarm systems when it is thought that the child sleeps too
deeply to be aware of the desire to void.
PFM contractions.
■ GIGGLE INCONTINENCE

Girls in particular go through a giggling phase around

puberty, if not before.
If the leakage is considerable an unstable detrusor should be
suspected.
Management: Pelvic floor exercises.
Not only should the girl practice regularly to build up
strength and endurance, but should also be encouraged to
develop the habit of contracting the pelvic floor before and
while giggling.
■ ORGASMIC INCONTINENCE

Many women have the urge to void urine during or

immediately after coitus and some experience actual
Incontinence.
Leakage of urine on penetration is more commonly
associated with GSI or detrusor instability.
Advice to empty the bladder prior to intercourse or to
change the coital position.
Drug therapy, with imipramine or oxybutinin chloride may be
prescribed for detrusor instability.
PFM exercises regularly.
 PHYSIOTHERAPY ASSESSMENT
■ History of the condition and details of present state.
■ Objective tests used
1. Frequency/ volume chart
Patient is asked to note the time of the day and to measure
the volume of urine voided each time she goes to the toilet.
■ A women with normal control does not usually void more than
six to eight times per 24 hours and does not wake up from
sleep to void.
■ Normal volumes voided are 250-459ml, with the first volume of
the day often being the greatest.
2. The pad test:
The test is started with the patient voiding.
Preweighed Absorbent perineal pad Is put on and the timing
begins.
Patient is asked not to void until the end of the test.
Patient drink 509 ml of sodium free liquid within 15 mins, then sits
or rests till the end of first half hour.
In the following half hour the patient walks around, climbs up and
down one flight of stairs, performs exercises such as
Standing up from sitting 10x
Coughing vigorously 10x
Running on spot for 1 minute
Bending down to pick up a small object 5x
Washing hands under cold running water for a minute
■ After the end of one hour the pad is removed and
weighed
Difference is recorded.
An increase of 1g is allowed as normal to compensate for
possible sweating and vaginal discharge.
3. Manual grading of PFM contraction strength
Physiotherapist must introduce a gloves index finger into the patient’s
vagina, ask the patient to contract the pelvic floor musculature, and
categorise what is felt.
Laycock and chiarelli proposed a six points scale
0. Nil contraction
1. Flicker of contraction
2. Weak
3. Moderate
4. Good
5. Strong
Also recommended measurement of duration of contraction in seconds
Eg; a grading of 2/7 indicates a weak squeeze held for 7 seconds.
4. Visual analogue scale
The patient is asked to place a cross at the appropriate point on a
10cm line, one end of which is marked ‘no leakage’/ ‘no
Incontinence’/ ‘no problem’ and the other end is marked ‘totally
incontinent’/ ‘massive problem’.
5. Urodynamic, radiological and emg assessment.
Other tests;
1. Cystometry: determines relationship between the volume of
fluid and the pressure in the bladder, during the filling and the
voiding phase.
2. Uroflowmetry : measures the quantity of fluid passed per unit
time.
3. Distal urethral electric conductance etc.
4. Anorectal manometry, etc.
■ Questionnaires
 PHYSIOTHERAPY MANAGEMENT

1. Pelvic floor contraction

■ Command: ask the patient to
Imagine-
1. Stopping passing water/ urine
2. Stopping doing a pee/ wee
3. Stopping yourself from farting
4. Trying to stop yourself from leaking/
wetting your pants
5. Gripping to stop a tampon from falling
out
■ Can be performed in any position but sitting on a hard
chair leaning forward to support forearms on knees with
things and feet apart is a useful initial position. Provides
sensory feedback.
■ It is helpful to focus attention on one opening at a time
■ Example of instructions:
1. Let’s think first about the back passage, imagine you
want to pass wind or empty your bowel, close shit your
back passage as tightly as possible. Now let go. Try twice
more.
2. Imagine full bladder, there are no toilets available and
you must wait. Squeeze shut your front passage tightly.
Now let go. 2x
3. For vaginal opening, imagine you have a tampon slipping
out and you are trying to grip it. 2x
■ Imagine your pelvic floor is like a lift standing on the
ground floor.
Contract your muscles underneath and take your lift up to
the first floor, closing shut all the three passages. Now let go.
Try again and let go.
Now try a cough, what happens to your pelvic floor? Yesit
goes down in the basement!
Now pull up your pelvic floor, hold it tight and give another
cough.
■ Duration and repetition:
At first session, ask the patient to hold a contraction strongly
until she feels the muscle weakening, time and record the
duration.
Then long, strong contraction are repeated one after another
with brief break, each held for as long as possible to see how
many contractions can be performed before serious fatigue
sets in.
Two ways of working your pelvic floor muscle
Quickly and slowly
First try a quick squeeze and let go, try that afew times. Now
close all the openings tightly shut and hold for as long as you
can then let go.
■ Check for other muscle contractions such as gluteal, adductors,
abdominal and also for breath holding.
■ General advice:
Contract the pelvic floor before events that triggers leakage
( coughing, sneezing, laughing, lifting, running, jumping, etc).
Exercise the pelvic floor in variety of situations such as driving,
telephoning, on the bus or train, watching television, etc.
■ Number of practice sessions: hourly or half hourly ( less
intensive sessions),
Or three intensive sessions per day.
■ Contractions: improvements were seen in patients with stress
incontinence using 8-12 groups of contractions, each of which
consisted of 1 contractions held for as long as possible followed
by 3-4 short ones. 3x a day. In variety of positions.
■ Perineometer
A compressible air-filled rubber portion (sensor) was inserted
into the vagina by the woman and attached by rubber tubing
to a manometer.
The women then contracts her pelvic floor several times and
notes the highest reading on the dial and the length of time
for which she could hold a contraction.
■ Foley catheter
An inflated cuffed catheter is used as a means of providing
woman with biofeedback for pelvic floor contractions.
There is stimulus from the presence of the catheter in the vagina,
threat of withdrawal, also gentle traction can be applied to
weight and stretch the PFM.
An inflated cuffed catheter is inserted into the vagina, preferably
by woman herself. She is then instructed to tense her pelvic floor
muscles to resist withdrawal of the catheter by the
physiotherapist.
Traction is gentle at first and is increased gradually.
Attempts are made to retain the catheter in the position during
activities that might cause leakage such as bending, coughing,
etc.
■ Vaginal cones
These consist of series of 5-9 small, progressively weighted
cylinders, ranging from 10g to 100g.
Made of lead coated with plastic and are about the size of a
tampon with a nylon string attached to one slightly tapered
end.
The lightest cone is inserted into the vagina by the women
while in the semi-squatting or half lying position or standing
with one foot up on a chair, with the cones pointed end and
string downwards.
Once the cone is in position the patient walks around. If the
cone can be retained for one minute the patient progresses
on to the next cone which is slightly heavier and so on until a
cone slips out in under one minute.
The heaviest cone that can be retained for a minute is used
for the exercise.
Session: twice a day walking around for approx 15 minutes.
If the cone can be retained without slipping for 15 mins –
switch to next.
■ General exercises
Assess for joint stiffness and generalized weakness that
might be affecting the PFM and treat accordingly.
■ Bladder training
It is used in the management of frequency, urgency without
leakage and urge incontinence.
Woman is required to keep a freq/ volume chart or diary for a
week which establishes her voiding pattern
Instructions in ways of delaying voiding:
Repeated PFM contraction when she feels the urge to void
Distraction – companionshio, games, TV, music etc.
■ Interferential therapy
Medium frequency currents in the region of either 4Khz or 2Khz
are currently being used therapeutically in the treatment of
urinary incontinence.
Has been used in cases of stress and urge incontinence.
Two slightly different medium- frequency currents are arranged to
crossfire and interfere with one another.
Low frequency current is produced in the area of interference.
At the point of application to the patient, med-freq currents have
advantage that the skin resistance is less.
The purpose of IT for patients with GSI is usually said to be the
production of contractions of the PFM as a means of the
increasing the patient’s cortical awareness, thus facilitating the
ability to perform voluntary contractions.
■ Application: patient is in half-lying position with the hips
and knees slightly flexed.
Two pole method:
One medium-sized electrode is placed over the anus,
covering the posterior fibres of the levator Ani muscle, and a
small electrode is positioned centrally immediately below the
symphysis pubis.
Four pole method:
Two electrodes on the abdomen just above the lateral portion
of the inguinal ligament. Two electrodes high on the internal
medial aspect of the thigh near the origin of the adductors.
Two electrodes medial to the ischial tuberosities i.e either
side of the anus and two electrodes lateral to the symphysis
pubis as nearly over the obturator foramen as possible.